**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy review, the facility failed to assess skin conditions after discovery to prevent a decline in the pressure wound for 1 of 3 residents reviewed (Resident #3). Resident #3 admitted to the facility with skin conditions of surgical incisions, some skin tears, and bruising on 11/29/23. During his time at the facility, he developed additional skin conditions that lead to a hospitalization due to an infection in his wounds. The hospital records revealed that Resident #3 had a pressure ulcer to his back, coccyx, and left heel. The record included those in addition to his fractures that happened prior to his admission to the nursing home of his left hip and shoulder. Resident #3's clinical record at the nursing home lacked documentation related to the pressure ulcers. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, with no tendon or muscle exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue) may be present on some parts of the wound bed, often including undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. Tissue in this area may have started as painful, firm, mushy, boggy, warmer or cooler tissue than adjacent areas. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 11/29/23. The MDS identified a Brief Interview of Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS indicated he had an impairment to one side of his upper and lower extremities. The MDS included diagnoses of pathological hip fracture, atrial fibrillation, anxiety, depression, and left shoulder fracture. Resident #3 had a risk for developing pressure ulcers, had no unhealed pressure ulcers/injuries, but did have surgical wounds. Resident #3 had a pressure reducing device for his chair and bed. The Baseline Care Plan dated 11/29/23 indicated Resident #3 had wounds other than pressure injury identified and the wound would heal without signs/symptoms of infection. The Interventions included: assess, document, and notify the physician of wound healing progress, administer medications, and supplements per physician's orders. The section labeled describe additional skin interventions, remained blank. The Baseline Care Plan reflected that he required assistance from one staff for bed mobility, transfers, walking, toileting and used a walker for locomotion. The Care Plan Focus dated 12/12/23 documented Resident #3 had the potential for the development of pressure ulcers related to immobility. The Interventions directed to follow facility policies/protocols for the prevention of skin breakdown, inform the resident and family of any new area of skin breakdown, and to treat pain as ordered prior to turning to ensure the resident is comfortable. Braden Scale Review Scores a. 11/29/23 - 18, indicating a low risk for the development of pressure ulcers. b. 12/4/23 - 10, indicating a high risk for the development of pressure ulcers. c. 12/11/23 - 15, indicating a low risk for the development of pressure ulcers. The Medication Review Report signed by the physician on 12/1/23 included the following orders: - 11/28/23: Complete Braden assessment every week on Mondays for 4 weeks upon admission, for skin integrity. - 11/29/23: Monitor left hip incision and keep clean, dry, and intact, every shift for health maintenance. Notify the physician of any signs/symptoms of infection. The Medication Review Report signed by the physician on 12/13/23 included the following orders: - 11/29/23: Monitor left hip incision and keep clean, dry and intact, notify physician of any signs and symptoms of infection, every shift for health maintenance. - 12/5/23: Mighty shake one time a day for wound healing. - 12/6/23: Cover all skin tear areas (left front shin, left lateral knee, right upper arm) with Mepilex every day until healed and then discontinue. - 12/7/23: Dressing (4x4 gauze and paper tape) to left hip every 1 hour as needed (PRN) for surgical incision healing. - 12/12/23: Left lower extremity wound: cleanse with wound cleanser, cover with calcium alginate with silver, then cover with super absorbent dressing every day shift for wound treatment. The Nursing Data Collection assessment dated [DATE] at 11:04 AM listed Resident #3 had skin integrity issues to his left hip of a surgical incision and to the left shoulder of bruising. The Health Status Note dated 11/29/23 at 12:23 PM indicated Resident #3 admitted to the facility following surgical repairs of a left hip and left shoulder fracture. He had sutures to his left thigh, with an abrasion. The wound wept through the dressing and required daily changes. The Fax dated 12/4/23 from the facility to the physician Resident #3 continued to want to stay in bed and sleep. He continued to get weak, with a poor appetite, an intake of approximately 25%, and a fair fluid intake. The note reflected the facility had concerns with Resident #3 may have depression. They planned to continue to encourage Resident #3 to get up to eat. The physician responded on 12/4/23 with an order for mirtazapine (antidepressant, appetite suppressant) 75 milligrams (mg). The Health Status Note dated 12/4/23 at 10:28 AM recorded the nurse faxed the doctor about Resident #3 staying in bed all the time, having a poor appetite, and acting depressed. The Health Status Note dated 12/4/23 at 5:22 PM reflected the completed skin check revealed areas present upon admission. The Fax dated 12/4/23 from the facility to the physician included a copy of Resident #3's skin sheet. The communication inquired for an order to cover skin tear areas with Mepilex every day until healed then discontinue. On 12/5/23, the provider responded, yes. The Health Status Note dated 12/5/23 at 2:39 PM listed the Dietitian faxed the provider recommendations to start Resident #3 with a mighty shake (nutritional supplement) every day for wound healing. Review of the hot charting binder revealed on 12/1/23-12/5/23 Resident #3 remained on skilled therapy status post (after) a left hip and shoulder fracture due to a fall. The Health Status Note dated 12/7/23 at 12:07 PM reflected Resident #3 returned from his physician appointment with his staples removed from his left hip with a dressing in place with instructions to change PRN. The Fax dated 12/11/23 from the facility to the physician indicated Resident #3's open areas on his left lower extremities didn't show improvement. The facility requested orders for: 1. Cleanse area with house wound cleanser. 2. Cover with Calcium Alginate with Silver; 3. Cover with super absorbent dressing; 4. Change every day until healed. On 12/12/23 - The provider responded yes. The Binder review for the dates on 12/5/23-12/11/23 resident remained on skilled therapy status post left hip and shoulder fracture due to a fall. New order for mirtazapine at bedtime for depression, multiple skin issues. The Order Note dated 12/12/23 at 12:48 AM indicated the facility received a fax with a new order to cleanse Resident #3's left lower extremity wound with wound cleanse, cover with calcium alginate with silver (dressing), cover with a super absorbent dressing, and change daily until healed. The Nursing Daily Skilled Assessment v.8 - v 4s from 11/29/23 until 12/13/23 lacked information related to Resident #3's skin condition, appearance, measurements, or an assessment. The Health Status Note dated 12/14/23 at 11:20 AM reflected Resident #3 continued to have a poor appetite, with a decrease in his fluid intake, increased lethargy, and didn't want to do anything. Resident #3 continued to have edema to his bilateral lower extremities, but denied pain. The nurse sent a fax to the clinic. The Health Status Note dated 12/14/23 at 2:30 PM described Resident #3 as shaky, similar to shivering and hard to arouse from sleep. The staff reported a decrease in urine output and called the clinic. The Health Status Note dated 12/14/23 at 3:00 PM reflected Resident #3's physician gave orders to send him to the emergency room. The Health Status Note dated 12/14/23 at 6:45 PM indicated the hospital reported they admitted Resident #3 for dehydration and right leg cellulitis (skin infection). The Hospital Physical assessment dated [DATE] at 9:32 PM listed Resident #3 reported his pain as a 5 (moderate pain) out of 10 (severe pain) due to his left hip fracture, left shoulder fracture, pressure sores to his coccyx, spine, and left heel. The section labeled Nursing Notes: listed the staff floated his heels, as he had a stage 3/unstageable pressure sore on his left heel. The staff used pillows to position Resident #3 with the plan to turn him every 2 hours to prevent further sores. The note amended on 12/14/23 at 11:32 PM indicated Resident #3 had the following wounds: a. Wound 1 location/type: decubitus ulcer, stage 3 and unstageable-eschar left heel. - Assessment/Interventions: surrounding tissue: red left open to air, heels floated. b. Wound 2 location/type: decubitus ulcer, stage 3 to his coccyx. - Assessment/Interventions: sacral mepilex dressing clean, dry and intact. c. Wound 3 location/type: decubitus ulcer, stage 3 to his spine, mepilex applied. Staff to turn Resident #3 sided to side every 2 hours. - Assessment/Intervention: mepilex dressing clean, dry and intact. The eInteract Transfer V3 form dated 12/14/23 at 3:00 PM listed Resident #3's admission date as 11/29/23 at 8:48 AM. The facility transferred him to a local hospital for increased lethargy (tiredness) and shakiness. The transfer form lacked information related to Resident #3's skin conditions. The Binder Review revealed on 12/11/23-12/15/23 Resident #1 remained on skilled therapy status post left hip and shoulder fracture due to a fall. He received a new order for mirtazapine at bedtime for depression, multiple skin issues. Decreased Lexapro (anti-depressant) due to interactions. The Hospital Physical Therapy note dated 12/16/23 at 1:20 PM described Resident #3's pressure ulcer on his spine as healing with improved epithelialization with bridge (strands or patches of tissue which form 'bridges' across the wound bed secondary to infection) through the inferior (lower part of wound) part of the wound. The staff redressed the pressure ulcer on thoracic spine (mid back) with Mepilex. The sacral wound looked improved, they redressed the wound with Mepilex and paper tape on the most inferior aspect to reduce chance of fecal (bowel) contamination. A new mepilex pad placed on his left heel as the wound still had black eschar (dead tissue). The Hospital Physical Therapy note dated 12/18/23 at 10:13 AM indicated the staff recommended a surgical consult to possibly perform surgical debridement (remove dead tissue to increase healing) of left heel ulcer. Two pillows placed under the resident to help prevent pressure sores while seated in the recliner. The Hospital Physical Therapy note dated 12/27/23 at 9:53 AM the dressing change to Resident #3's thoracic spine wound revealed a lot of good red granulation tissue (new tissue) with minimal white (possible sign of healing) showing. On 12/27/23 at 10:34 AM the Hospital Nurse that admitted Resident #3 stated she didn't see anything about pressure ulcers on his transfer form, and the nursing home staff didn't report any to her. She explained he had pressure sores on his spine and coccyx (tailbone). She reported he had a wound to his left heel. The wound appeared half open, while the other half looked necrotic. The wound looked black, but not leathery. Resident #3 had multiple skin tears on his arms and legs. His legs appeared banged up too. On 12/27/23 at 11:05 AM Staff F, Licensed Practical Nurse (LPN), explained Resident #3 admitted towards the end of her shift. She remembered during the nursing report he had skin issues to his left arm, on his foot, but couldn't remember if it was at the top of his foot and a scratch on one of his legs. She looked up his admission skin assessment and read it. The skin assessment indicated he had bruises on right back leg, left abdominal side and back of left leg. He had skin tears on his left front shin, left outside knee, right upper arm, another on his left outside knee, and left upper arm. He also had surgical sites to the outside of his left knee and 3 different ones on his left hip. On 12/27/23 at 11:13 AM Staff L, Certified Medication Aide (CMA), stated Resident #3 transferred with two persons with an EZ-stand (standing mechanical lift) but he didn't like to get up often and he didn't like to eat. He had edema in his legs that wept all the time. Staff L believed he had failed to thrive. When asked if he had any other skin concerns she responded he had a sore on his back from the use of a gait belt or EZ-stand, and they covered his wound due to that reason. Staff L reported she didn't believe he had anything on his bottom or heel and that she didn't know anything else. On 12/27/23 at 11:20 AM Staff E, Physical Therapist Assistant (PTA), explained Resident #3 didn't transfer well, had cognitive issues, and was hard of hearing. She indicated his lower extremities wept all the time. They tried to pad his spine because it seemed like anytime they tried to use the gait belt it would put pressure on his spine. The nursing staff applied a pad dressing to the area for protection. He was compliant with therapy and would always try but it was hard for him. On 12/27/23 at 1:45 PM Staff G, LPN, reported Resident #3 needed assistance from two persons and/or EZ-stand but he didn't want to do a lot. He had a poor appetite and wanted to stay in bed. Resident #3 allowed staff to help reposition him but they had to be careful because of his hip fracture repair. When asked if he had any skin issues or wounds, he replied he had a lot of bruising before his admission, with skin tears, and surgical wounds on his left leg. When asked if Resident #3 had wounds on his bottom or heels, Staff G denied wounds. He added he had edema to both lower extremities, with weeping on his right lower leg. On 12/28/23 at 9:04 AM Staff K, Certified Nursing Assistant (CNA), stated Resident #3 always wanted to be in bed but when he got up they transferred him by stand-pivot, then he changed to assistance of two persons with the EZ-stand. She stated his legs leaked and she thought he had cellulitis, but the nurses knew that. The nurse told them to lay him down but that didn't solve his issue. When asked if he had other skin concerns, she responded Resident #3 had 2-3 discolored but couldn't remember if open spots on his buttocks with a surgical site to his hip. Staff K knew he got those from his fall before his admission to the facility. She denied any skin concerns to his back or heels other than bruises. They started to use the EZ-stand because the gait belt hurt his back. She added he repositioned well from side to side. She reported the discoloration on his buttocks to Staff H, LPN. On 12/28/23 at 12:00 PM Staff A, CMA, reported Resident #3 wanted to lay in bed all the time. He had cellulitis on his legs and didn't know if he had it on both legs or not. She informed Staff H that the wound wept and it needed to be wrapped. When asked if he had a sore on his bottom, she replied she didn't see it due to a Band-Aid on it. He had a big bruise on his back, which prevented them from using a gait belt with him, so they started to use an EZ-stand to transfer him. Staff H told her the nurses knew about that, but she couldn't recall anything on his heels. He was compliant with repositioning. On 12/28/23 at 1:00 PM Staff H reported she vaguely remembered Resident #3 and couldn't remember if he had skin issues. When asked what she would do if a resident had a new skin issue, she responded she typically did a skin assessment, notify the family, and the physician. On 12/28/23 at 1:33 PM Staff J, CNA, reported Resident #3 liked to stay in bed, and didn't have a repositioning program but he would allow them to reposition him. He had a broken hip so he had pain but repositioned. When asked if he had any skin issues she stated the last few days before going to the hospital his legs wept, but she didn't notice any open areas. She couldn't remember if he had bruising or redness to his bottom or heels. She added he wouldn't eat a lot. When asked what she would do if she noticed new skin issues on a resident, she explained she would tell the nurse, and if they didn't do anything, she would tell the next nurse. On 12/28/23 at 2:37 PM Staff I, Registered Nurse (RN), described herself as usually being the charge nurse on duty and didn't work Resident #3's hall. If the other staff had concerns they came to her about them. She remembered Resident #3 had incision sites to his hip and arm from his surgery prior to coming to the facility. She believed he had issues with his legs and maybe bottom but could not recall the specifics. On 1/2/24 at 12:49 PM during an attempted call to Resident #3's physician, the nurse reported he would be out of the office for the week. On 1/10/24 at 11:21 AM attempted another call to Resident #3's physician. The Hospital Director reported the doctor was out of the office and added he would message him to tell him to return the surveyor's call. At the end of the survey the physician didn't return the call. On 1/10/24 at 1:01 PM the Assistant Director of Nursing (ADON)/MDS Coordinator stated the previous Director of Nursing (DON) did Resident #3's Baseline Care Plan. When she completed his MDS it guided her to update his Care Plan to reflect his risk for pressure ulcers. Resident #3 admitted to the facility for Physical and Occupational Therapy due to a broken hip and shoulder. The ADON/MDS Coordinator described him as a tiny, small man that didn't have a lot of meat on his bones. When asked if he had any skin issues, she indicated she only remembered a spot on his back because he had no meat on his bones. When PT used a gait belt it rubbed on his back. In addition, he had a surgical wound but didn't remember having any pressure ulcers or anything of that nature. The ADON/MDS Coordinator reviewed the skin assessments and when asked why no one completed a skin assessment for the area on Resident #3's back, she replied PT would have reported that to the nurse. When asked about the band aid and discoloration to his bottom, she responded she needed to look through the progress notes but if he had issues, the weekly skin assessment would include them. When notified the hospital found stage III pressure ulcers to his spine, coccyx, and heel she exclaimed oh someone should have documented about that, but she would need to review his chart. After informing her, his clinical record lacked documentation in his progress notes, weekly skin assessments, skilled assessments, and documents tab she replied that is where she would look, too. She indicated she would look to see what she could find. On 1/10/24 at 1:15 PM the ADON/MDS Coordinator returned with a fax to the doctor about Resident #3's open areas to his lower extremities not improving. She reported that it was all she could find at that time. On 1/10/24 at 1:50 PM Staff M, previous DON, reported Resident #3 came to the facility on skilled therapy due to a hip fracture and dislocated shoulder. At his admission, he looked extremely bruised on his left side to his face and shoulder, however, his hip incision looked good. They completed a head-to-toe assessment and remembered documenting a stage 1 or redness on his buttocks. At that time, they applied a barrier cream. He could reposition himself independently with an assist bar while in bed. She believed he moved side-to-side by himself. After informing Staff M about the skin issues the hospital documented on his coccyx, spine, and heel, she responded she didn't remember the issue with his spine. He was in therapy early in his stay when therapy staff showed her his spine. He was malnourished so they put sheepskin on the back of his wheelchair for protection. He had no open areas at that time and they only did it as a preventative measure. He had a bony back that made it easy to see his spine but the skin didn't have breaks. She added the area didn't happen overnight. She could not recall any concerns with his heels, but Resident #3 had redness on his coccyx, and they used a barrier cream. On 1/11/24 at 9:03 AM Staff E provided the Physical Therapy Treatment Encounter note dated 12/13/23. The note indicated following Resident #3's walk, she noticed an area on his thoracic spine with skin tears/shearing from use of the gait belt. The area happened with a barrier between his skin and the belt. Noted redness on right lateral rib area. Nursing notified/addressed/treated. Staff E electronically signed the note on 12/13/23 at 3:52 PM. On 1/11/24 at 9:47 AM the Administrator stated she could only find a fax from 12/4/23 about getting orders to cover Resident #3's skin tears with a Mepilex every day until healed then discontinues. When informed the fax didn't address his spine, coccyx, and heel wounds, she replied that was all she could find for his orders. On 1/12/24 at 12:17 PM the Regional Nurse Consultant reported the abrasion on Resident #3's back happened when they used the gait belt. She indicated she would need to look in his chart to see about the documentation for that abrasion. She explained on 12/11/23 included his last weekly skin assessment and the note lacked documentation of his spine, coccyx, or heel injuries. When informed the hospital documented he had stage III decubitus ulcers to those areas, she responded they reached out to the hospital for his history and physical. When she spoke to the staff no one reported skin concerns. She indicated she spoke with the PTA that worked with him as well. After notifying the Regional Nurse Consultant that Resident #3's clinical record lacked documentation that Staff E found a skin tear/shearing to his thoracic spine, she replied she would need to look at his chart. The facility's Skin Care and Wound Management policy dated June 2015 indicated the facility staff strived to prevent resident skin impairment and to promote the healing of existing wounds. The interdisciplinary team worked with the resident and/or family/responsible party to identify and implement interventions to prevent and treat potential skin integrity issues. Components of the skin care and wound management program include at least the following: - Weekly monitoring of resident skin status - Daily monitoring of existing wounds - Application of treatment protocols based on clinical best practice standards for promotion of wound healing. - Monitoring for consistent implementation of interventions and effectiveness of interventions. - Review and modification of treatment plans, as applicable. Treatment: - Obtain a physician's order for the identified protocol or treatment order - Document treatment protocols on the TAR - Monitor and document progress towards goals - Communicate changes to the caregiving team, resident/patient and/or family/responsible party. The form defines a pressure ulcer as a localized injury to skin and/or underlying tissue usually over a bony prominence, because of pressure or pressure in combination with shear and/or friction.